Abdominal Aortic Aneurysm

Abdominal Aortic Aneurysm (AAA)

Abdominal aortic aneurysm (also known as AAA) is a localized ballooning of the abdominal aorta exceeding its normal diameter by more than 50 percent, and is the most common form of aortic aneurysm. Approximately 90 percent of abdominal aortic aneurysms occur below the kidneys, but they can also occur at the level of the kidneys or above the kidneys.

Such aneurysms can extend to include one or both of the iliac arteries in the pelvis. Abdominal aortic aneurysms occur most commonly in individuals between 65 and 75 years old and are more common among men and smokers. They tend to cause no symptoms, although occasionally they cause pain in the abdomen and back (due to pressure on surrounding tissues) or in the legs (due to disturbed blood flow).

The major complication of abdominal aortic aneurysms is rupture, which can be life-threatening as large amounts of blood spill into the abdominal cavity, and can lead to death within minutes. Symptomatic and large aneurysms (i.e., those greater than 5.5 cm in diameter) are considered for repair by one of several surgical methods. There is moderate evidence to support screening in individuals with risk factors for abdominal aortic aneurysms.

The vast majority of aneurysms are asymptomatic. However, as abdominal aortic aneurysms expand, they may become painful and lead to pulsating sensations in the abdomen or pain in the chest, lower back, or scrotum. The risk of rupture is high in a symptomatic aneurysm, which is therefore considered an indication for surgery.

The complications include rupture, peripheral embolization, acute aortic occlusion, and aortocaval or aortoduodenal fistulae. On physical examination, a palpable abdominal mass can be noted. Bruits can be present in case of renal or visceral arterial stenosis.

The clinical manifestation of ruptured AAA usually includes excruciating pain of the lower back, flank, abdomen and groin. The bleeding usually leads to a hypovolemic shock with hypotension, tachycardia, cyanosis, and altered mental status. The mortality of AAA rupture is up to 90%. 65-75% of patients die before they arrive at hospital and up to 90% die before they reach the operating room. The bleeding can be retroperitoneal or intraperitoneal, or the rupture can create an aortocaval or aortointestinal (between the aorta and intestine) fistula. Flank ecchymosis (appearance of a bruise) is a sign of retroperitoneal hemorrhage, and is also called Grey Turner's sign.

Cigarette smoking: More than 90% of people who develop an AAA have smoked at some point in their life.

Genetic influences: The influence of genetic factors is highly probable. The high familial prevalence rate is most notable in male individuals. There are many theories about the exact genetic disorder that could cause higher incidence of AAA among male members of the affected families.

Some presumed that the influence of alpha 1-antitrypsin deficiency could be crucial, some experimental works favored the theory of X-linked mutation, which would explain the lower incidence in heterozygous females. Other theories of genetic etiology have also been formulated. Connective tissue disorders, such as Marfan syndrome and Ehlers-Danlos syndrome, have also been strongly associated with AAA. Both relapsing polychondritis and pseudoxanthoma elasticum may cause abdominal aortic aneurysm.

Atherosclerosis: AAA was long considered to be caused by atherosclerosis, because the walls of the AAA are frequently affected heavily. However, this theory cannot be used to explain the initial defect and the development of occlusion, which is observed in the process.

Other causes: Other causes of the development of AAA include: infection, trauma, arteritis, cystic medial necrosis.

An abdominal aortic aneurysm is usually diagnosed by physical exam, ultrasound, or CT. Plain abdominal radiographs may show the outline of an aneurysm when its walls are calcified. However, this is the case in less than half of all aneurysms. Ultrasonography is used to screen for aneurysms and to determine the size of any present. Additionally, free peritoneal fluid can be detected. It is noninvasive and sensitive, but the presence of bowel gas or obesity may limit its usefulness. CT scan has a nearly 100% sensitivity for aneurysm and is also useful in preoperative planning, detailing the anatomy and possibility for endovascular repair. In the case of suspected rupture, it can also reliably detect retroperitoneal fluid. Alternative less often used methods for visualization of the aneurysm include MRI and angiography.

An aneurysm ruptures if the mechanical stress exceeds the local wall strength; consequently, peak wall stress (PWS) and peak wall rupture risk (PWRR) have been found to be more reliable parameters than diameter to assess AAA rupture risk. Medical software allows computing these rupture risk indices from standard clinical CT data and provides a patient-specific AAA rupture risk diagnosis.

Surgery for an abdominal aortic aneurysm is known as AAA surgery or AAA repair. The threshold for repair varies slightly from individual to individual, depending on the balance of risks and benefits when considering repair versus ongoing surveillance. The size of an individual's native aorta may influence this, along with the presence of comorbidities that increase operative risk or decrease life expectancy.

Open repair

Open repair is indicated in young patients as an elective procedure, or in growing or large, symptomatic or ruptured aneurysms. It was the main surgical intervention used from the 1950s until other procedures developed.

Endovascular repair

Endovascular repair first became practical in the 1990s and although it is now an established alternative to open repair, its role is yet to be clearly defined. It is generally indicated in older, high-risk patients or patients unfit for open repair. However, endovascular repair is feasible for only a proportion of AAAs, depending on the morphology of the aneurysm. The main advantages over open repair are that there is less peri-operative mortality, less time in intensive care, less time in hospital overall and earlier return to normal activity. Disadvantages of endovascular repair include a requirement for more frequent ongoing hospital reviews, and a higher chance of further procedures being required. According to the latest studies, the EVAR procedure does not offer any benefit for overall survival or health-related quality of life compared to open surgery, although aneurysm-related mortality is lower. In patients unfit for open repair, EVAR plus conservative management was associated with no benefit, more complications, subsequent procedures and higher costs compared to conservative management alone. Endovascular treatment for paraanastomotic aneurysms after aortobiiliac reconstruction is also a possibility.